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Taking It in the Teeth 

Budget crisis decimates dental care options for the poor

Wayne Atkins is in a race: against cancer and the California budget.

The state's decision to eliminate adult dental care and eight other "optional" benefits from the Medi-Cal program effective July 1 recently sent Atkins and countless other North Coast residents into an all-out scramble to complete costly dental work prior to the state's funding cutoff. In Atkins' case, chemical and radiation therapies prescribed after the removal of a malignant tumor from his throat weren't optional. Neither was having his teeth removed at the start of the year.

"They took them out so there'd be no chance of infection," Atkins said in late May. "That was my choice: lose my teeth or no chemo."

Now that his cancer treatments are done, Atkins has five dental appointments scheduled this month at the Burre Dental Center. He hopes to have his dentures in place by July 1.

Daniel Huffman isn't so lucky.

"They gave me this contract that said Medi-Cal was going to be gone and they may not be able to get all the denture work done before then," Huffman said after a mid-week visit to a crowded Burre center. "They told me in a worst-case scenario it might end up costing me $1,500 to $1,600. I ain't got that kind of money and there's nowhere I can get it."

The same applies to the state. Leaders reached a budget agreement in February that cut not only the $56 million provision for adult dental care but also the so-called optional coverage for chiropractic services, acupuncture, psychological care, podiatry, audiology, optometry and speech therapy. The news got worse in late May, when government leaders announced a series of draconian cuts to close what is now a projected $24.3 billion deficit.

"Forty percent of our income comes from Medi-Cal, and all of that is under threat," said Hermann Spetzler, executive director of the Open Door Community Health Centers.

Spetzler said the Open Door system is looking at all sorts of what-if scenarios. Some painful decisions have already been made. After 31 years of serving patients in Arcata, the Open Door dental clinic will shut its doors on June 28. Last year, that site accounted for about 8,200 adult patient encounters -- almost 160 visits per week.

Dental care offered through the Mobile Medical unit is up in the air, and Old Town Dental Center in Eureka will close this fall after Burre Dental Center is expanded from 12 to 16 chairs. Two dentists leaving Open Door at the end of this month will not be replaced, leaving the system with seven rather than the 11 budgeted in the prior fiscal year.

"The potential loss is in the millions," Spetzler said of the Medi-Cal cuts. "I can only retain the staff we can afford to pay, and we can't fool ourselves into thinking health care doesn't cost money."

Spetzler and Cathy Larsen of the Southern Trinity Health Services fear the community at large fails to realize the proposed cuts impact more than dental services, which they see as one leg of a three-legged stool. Collapse one leg and threaten the entire platform of primary care health services that are, in some cases, the only services available in rural areas.

"If you are the only provider in an area and are destabilized because 40 percent of your income is threatened, it doesn't matter if the clients have health insurance or not: They won't have access," Spetzler said.

"Fifty-five percent of my stool is dental and another 10 percent is counseling," Larsen said. "There is a real possibility we will not be able to weather it. There's no way for us to maintain primary care services and the ambulance service given these conditions."

Larsen presides over a district that serves 4,300 people and 1,250 square miles in the southern portion of Trinity County and the southeast corner of Humboldt County. Formed 32 years ago to provide ambulance service, the district and its 22 employees had slightly more than 8,000 client visits last year.

"Many of the patients out here are low-income retirees or families struggling to stay out here since the logging decline that started in the '70s," Larsen said. "They have nowhere to go."

Larsen is putting up a fight. Southern Trinity Health Services joined with the California Primary Care Association and Clinicas Del Camino Real Inc. in Ventura to file a lawsuit to stop the state from eliminating the Medi-Cal benefits currently being provided by California's federally qualified rural health centers.

A hearing is scheduled for tomorrow (June 12) at 11 a.m. in Sacramento County's Superior Court.

"It's grave for us and the community," Larsen said. "We're the largest employer in the area, and we will have to lay people off and cut some full-timers to part-time with a loss of benefits. I'm praying for a miracle."

So is Huffman. Without a miracle, he figures it will take him two years to afford a full mouth of teeth.

"That's bullshit when I think about how long I've been trying to get in there," he said. "But I don't want to die."

Huffman is a diabetic, and diabetics are prone to infections that often begin in the mouth or the feet. A month ago he had an infection in his mouth and a note from his doctor asking the Burre Center to see him.

"They said, 'Sorry. Can't help you,'" Huffman recalled. With the dental clinics backed up and no private dentists in Humboldt County taking Medi-Cal patients, Huffman ended up at the St. Joseph Hospital emergency room with an abscessed tooth.

"The pain was like nothing I've ever felt," the 52-year-old former Marine said. "I've gone to the emergency room before for my feet, but never for a tooth. They gave me antibiotics and said if you have any trouble, call us back."

"They can't do anything else," said Larsen, executive director for Southern Trinity Health Services. "The ER tells them go see a dentist. When they can't find one, and the antibiotic wears off, that abscessed tooth will come right back up. They'll end up in the emergency room or they'll die because an abscessed tooth is a major infection."

Dental care isn't an "optional benefit" for diabetic patients any more than teeth are an optional body part. Larsen said dental disease has been linked to heart disease, low birthweight and the ability to regulate blood sugars, even with medication.

"There's such a strong link that Aetna (health insurance) has for some time given free oral health care to all diabetic patients because it is cheaper for them to give dental care away than to absorb the costs associated with managing health care for those who don't have it," she said. "It's a matter of economics to them."

"Short-sighted" is how the cut was described by Mark Kirkland, dentist and associate dean for clinical affairs at the UC San Francisco School of Dentistry.

"People will postpone routine dental care and show up in the hospital seeking care for tertiary problems. It's more expensive," he said.

Spetzler said a study fresh from the California HealthCare Foundation shows the average visit to the ER for dental care is $660 -- almost six times as expensive as the clinic visits that are soon to be un-reimbursed.

"Once someone hits the emergency room, we all pay for it," Spetzler said. "Resources have to come from somewhere."

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